28 Jun 2023 George Edward GRIFFITHS · Prevention of Future Deaths report Herefordshire
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Concerns raised 5 Failure to remove footwear for foot inspection View source Failure to appropriately manage or refer necrotic toes View source Delays in reassessment and implementation of pressure relieving measures View source Lack of preventative pressure area care View source Failure to mandate pressure area care training View source See 2 more concerns
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AI-generated summary
George Edward GRIFFITHS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Edward GRIFFITHS was admitted to hospital with acute kidney injury, gastritis, poorly controlled diabetes and infected toes, and later developed sepsis, COVID, delirium and a significant pressure sore during his prolonged admission. The report states that doctors believed the hospital-acquired pressure sore contributed to his death. Concerns included prolonged time in the emergency department without footwear removal, inadequate pressure-area prevention and delayed reassessment and pressure-relieving measures.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remove footwear for foot inspection
Wider context from the report “(1) The patient appears to have been held in ED for 40+ hours during which time footwear was not removed . Necrotic Toe apparent without evidence of appropriate management or referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately manage or refer necrotic toes
Wider context from the report “(1) The patient appears to have been held in ED for 40+ hours during which time footwear was not removed. Necrotic Toe apparent without evidence of appropriate management or referral .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reassessment and implementation of pressure relieving measures
Wider context from the report “(2) Skin inspection on admission confirmed that all areas were intact but there is no evidence of preventative care despite patients’ time on ED (40 hours) and in AMU (5 days). Acknowledgement of pressure area damage occurred on the 8th February but no reassessment took place until the 20th February with consequent failure to implement pressure relieving measures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of preventative pressure area care
Wider context from the report “(2) Skin inspection on admission confirmed that all areas were intact but there is no evidence of preventative care despite patients’ time on ED (40 hours) and in AMU (5 days). Acknowledgement of pressure area damage occurred on the 8th February but no reassessment took place until the 20th February with consequent failure to implement pressure relieving measures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to mandate pressure area care training
Wider context from the report “(3) The Pressure Sore acquired in Hospital contributed to the death and it is noted that pressure area care training is not mandatory within Wye Valley Trust .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly multidisciplinary Pressure Ulcer panels and use rapid reviews to identify omissions, rectify care and capture learning.
Verbatim wording from the response “The Trust also holds a weekly Pressure Ulcer panel with subject matter experts (Tissue Viability/ Safeguarding/ Quality & Safety/ Therapies/ Matrons) where all incidences of pressure damage are discussed. Ward managers are invited to complete rapid reviews so that any omissions of care can be identified and rectified and to ensure learning takes place.” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an automated dashboard showing assessment and care-plan status to nurses in charge.
Verbatim wording from the response “Having moved from a paper assessment and care planning system onto a digital platform we have recognised that senior nursing oversight (nurse in charge) of the status of all patient assessments is not as accessible and obvious as when documentation was kept at the end of the patients’ bed. Part of our improvement plan is to develop an automated dashboard on the digital system, which will enable the nurse in charge to check the status of assessments and care plans for all patients in their charge. In addition, the assessment document itself is being reviewed to simplify the steps for completion and to add in prompts for accessing equipment/referring for specialist advice etc.” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide new pressure-relieving mattress toppers on all Emergency Department trolleys.
Verbatim wording from the response “The ED department has recently invested in new mattress toppers for all ED trolleys to mitigate the risk of patients developing pressure damage in the event a patient has a longer than expected wait in the department and for those patients most at risk a bed and air mattress can be requested.” Source location Response from Wye Valley NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Trust pressure-area-care policy to cover Emergency Department care.
Verbatim wording from the response “A thematic review of pressure damage cases in ED has also identified further areas for improvement that will be formalised into a departmental improvement plan. This includes a review of our Trust policy, which currently focusses on pressure area care in inpatient areas. The policy is being updated and an” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an Emergency Department standard operating procedure for timely, systematic pressure-area care.
Verbatim wording from the response “A thematic review of pressure damage cases in ED has also identified further areas for improvement that will be formalised into a departmental improvement plan. This includes a review of our Trust policy, which currently focusses on pressure area care in inpatient areas. The policy is being updated and an” Source location Response from Wye Valley NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modify the equipment-library request process so pressure-relieving mattresses and chair cushions are routinely supplied together.
Verbatim wording from the response “Early identification of the need for pressure relieving equipment is crucial to support better pressure area care. The Trust has modified the request process from the equipment library so that pressure relieving mattresses and chair cushions are provided routinely as part of the same request.” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and simplify the assessment document, adding prompts for equipment and specialist referrals.
Verbatim wording from the response “Having moved from a paper assessment and care planning system onto a digital platform we have recognised that senior nursing oversight (nurse in charge) of the status of all patient assessments is not as accessible and obvious as when documentation was kept at the end of the patients’ bed. Part of our improvement plan is to develop an automated dashboard on the digital system, which will enable the nurse in charge to check the status of assessments and care plans for all patients in their charge. In addition, the assessment document itself is being reviewed to simplify the steps for completion and to add in prompts for accessing equipment/referring for specialist advice etc.” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and pilot a local pressure-area-care competency package in high-risk clinical areas.
Verbatim wording from the response “In addition to core training, e-learning modules are available for all staff to refresh their skills and knowledge. A local competency package has been developed and has been piloted in areas where patients are most at risk (Frailty service). Once this has been evaluated, the competency programme will be rolled out more widely in the Medical Division, which will include the Emergency Department and Acute Medical Unit.” Source location Response from Wye Valley NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh Tissue Viability link-nurse roles and provide additional training to their role holders.
Verbatim wording from the response “The Trust has Tissue Viability link nurse roles across the wards and relevant departments. This role has been refreshed as part of our overarching improvement plan and the individuals have received additional training. These members of staff are ‘on the ground’ experts and can provide timely advice and make recommendations for treatment plans. In addition, the Tissue Viability team are there to provide specialist advice if the ward based team feel specialist input is required and referral is necessary.” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce senior nurse care reviews for patients spending extended periods in the Emergency Department.
Verbatim wording from the response “The ED has since recognised the need to implement new ways of working in response to the sustained pressures and patients spending far longer in the department than we would like. In response, we introduced a senior nurse care review, to meet the needs of those patients spending a long time in ED waiting for a bed. The care review is akin to the review ward based nurses would undertake and is intended to ensure that comprehensive care assessments and planning that would not ordinarily happen in an Emergency Department are undertaken.” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the competency programme across the Medical Division, including Emergency Department and Acute Medical Unit areas, after evaluation.
Verbatim wording from the response “In addition to core training, e-learning modules are available for all staff to refresh their skills and knowledge. A local competency package has been developed and has been piloted in areas where patients are most at risk (Frailty service). Once this has been evaluated, the competency programme will be rolled out more widely in the Medical Division, which will include the Emergency Department and Acute Medical Unit.” Source location Response from Wye Valley NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory pressure area care training is not considered necessary because relevant education is included in existing staff training and induction arrangements.
Verbatim wording from the response “Whilst pressure area care training is not mandatory at the Trust, front line nurses and nursing associates do receive pressure area prevention, assessment and care planning education as part of their core pre-registration training and for health care support staff this is taught as part of their care certificate and clinical skills training or induction to the organisation. Given the Trusts improvement plan and desire to improve clinical practice the Chief Nursing Officer has also contacted the local university to check that the pre-registration curriculum remains fit for purpose in this regard.” Source location Response from Wye Valley NHS Trust
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3 Aug 2022 Alison June Dallow · Prevention of Future Deaths report Herefordshire
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Concerns raised 3 Unclear clinical advice on weight-bearing status View source Unclear hospital policy for reducing venous thromboembolism risk in outpatients View source Failure to record information given to patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Alison June Dallow · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alison June Dallow died from a pulmonary thromboembolism due to deep vein thrombosis after a fractured left tibial plateau and reduced mobility associated with the fracture and a knee brace. The concerns included unclear advice about weight-bearing, unclear hospital policy on reducing venous thromboembolism risk for outpatients, and unavailable evidence of information given to the patient.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear clinical advice on weight-bearing status
Wider context from the report “(1) It was unclear whether the clinical advice was to ‘toe touch’ or stay non- weight bearing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear hospital policy for reducing venous thromboembolism risk in outpatients
Wider context from the report “(2) The current hospital policy in connection with reducing the risk of Venous Thromboembolism was unclear especially regarding outpatients who apparently account for the majority of fractures treated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record information given to patients
Wider context from the report “(3) Evidence of any information given to the patient was unavailable at the Inquest.
” Open source report
1 Apr 2020 Jake Thomas PERRY · Prevention of Future Deaths report Herefordshire
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Concerns raised 2 Lack of a named local hospital Consultant for patients with conditions overseen by another hospital View source Failure to consult the overseeing hospital’s relevant specialist department when admitted patients have conditions overseen by another hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jake Thomas PERRY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jake Thomas PERRY died after water-soluble B-group vitamins were removed from his parenteral nutrition. The report identifies concerns about variation of the parenteral nutrition and communication between hospitals, including local consultant responsibility and specialist consultation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a named local hospital Consultant for patients with conditions overseen by another hospital
Wider context from the report “Concern relates to the variation of the Parenteral Nutrition and communication
1. Patients with a medical condition overseen by another hospital should have a named Consultant at their local hospital.
2. Where a patient is admitted and has a medical condition overseen by another hospital the specialist department (generally involved in the patient’s care) of the overseeing hospital (in addition to any other specialist hospital or department) should be consulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult the overseeing hospital’s relevant specialist department when admitted patients have conditions overseen by another hospital
Wider context from the report “Concern relates to the variation of the Parenteral Nutrition and communication
1. Patients with a medical condition overseen by another hospital should have a named Consultant at their local hospital.
2. Where a patient is admitted and has a medical condition overseen by another hospital the specialist department (generally involved in the patient’s care) of the overseeing hospital (in addition to any other specialist hospital or department) should be consulted.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate divisional standard operating procedures requiring named local consultants and consultation with relevant specialist departments at the overseeing hospital.
Verbatim wording from the response “1. Patients with a medical condition overseen by another hospital should have a named consultant at their local hospital.” Source location 2020-0091-Response-from-Wye-Valley-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop patient information proformas covering involved professionals and admission management plans, with annual consultant review and updating.
Verbatim wording from the response “1. To improve the information held on patients with open access to the children’s ward.” Source location 2020-0091-Response-from-Wye-Valley-NHS-Trust_Redacted
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1 Feb 2019 Mary Bertha Johnson · Prevention of Future Deaths report Herefordshire
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Concerns raised 3 Failure to adhere to Consultant instructions on medication provision prior to operation View source Failure to ensure feeding of patients prior to operation View source Insufficient porter availability limiting theatre operations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mary Bertha Johnson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Bertha Johnson died at County Hospital, Hereford, on 25 July 2018 after falling on 20 July 2018 and sustaining a periprosthetic fracture of the femur. Concerns included poor communication about feeding and medication before surgery, and the suggestion that porter availability affected the hospital theatres’ ability to carry out operations.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to Consultant instructions on medication provision prior to operation
Wider context from the report “(1) A lack of communication between staff highlighted issues concerning:
(a) the feeding of patients prior to operation
(b) adherence to the Consultant’s instructions regarding the provision of medication prior to operation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure feeding of patients prior to operation
Wider context from the report “(1) A lack of communication between staff highlighted issues concerning:
(a) the feeding of patients prior to operation
(b) adherence to the Consultant’s instructions regarding the provision of medication prior to operation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wye Valley NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient porter availability limiting theatre operations
Wider context from the report “(2) It was suggested that the availability of porters determined the ability of the hospital theatres to carry out operations
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relaunch and clarify thromboprophylaxis guidance for relevant staff, including when prophylaxis should be withheld before surgery.
Verbatim wording from the response “Although not actually the root cause for this patient’s death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis prior to surgery, particularly the time period before which it should be withheld. In addition to this, and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and I would be happy to update you on the progress of this at a later date.” Source location 2019-0458-Response-by-Wye-Valley-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all specialty-specific thromboprophylaxis guidelines.
Verbatim wording from the response “Although not actually the root cause for this patient’s death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis prior to surgery, particularly the time period before which it should be withheld. In addition to this, and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and I would be happy to update you on the progress of this at a later date.” Source location 2019-0458-Response-by-Wye-Valley-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient was fed appropriately and food and fluids were appropriately restricted before the planned operation.
Verbatim wording from the response “Following our investigations, I can confirm that the patient was fed appropriately throughout her stay on the ward and placed nil by mouth, i.e. food and fluids restricted appropriately, prior to the planned operation on Tues 24th July 2018. The investigation has established that the consultants’ instructions were not adequately adhered to over the weekend in question. The plan, quite clearly placed in the notes by the consultant team, for Mrs Johnson to be operated on Monday 23rd July. Fortunately, this instruction appears not to have been read by the nurse caring for the patient over the weekend in question. This nurse appeared to have been under the impression that this patient was to be operated on over the weekend and hence withheld the prescribed thrombo prophylaxis.” Source location 2019-0458-Response-by-Wye-Valley-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Porter availability had no material effect on the patient's outcome.
Verbatim wording from the response “The investigation has established that the availability of porters had no material effect on this patient’s outcome.” Source location 2019-0458-Response-by-Wye-Valley-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations